Bibliographical Notices

abialnig from th un of apersts, but bSdmin *a= to accompli it. the dwrationof reos wi ury of courthm individual cus; but aouthorities sy, wtsome hour in all should be allowed to elapse before rents ar administered. The quntity of opium will with the cae, and will depend upon whether the tent has been brought under its influence during the of the taxis. In the present case, the patient confnued drowsy after the operation was completed, and none wa given until the bowels were relieved. Mr. Gutlirie recommends that one grain should be given two or three times a day, according to its effect, for the first two days, and be followed up by a large emollient enema at the expiration of that time. I confess that I was not sufficiently delivered from the trammels with which the long inculcated -orthodoxy of the aperient treatment had entwined me, to wait so long; but when the vomiting and pain that occurred on their administration supervened on a hitherto favourable condition, I repented of my adherence to past teching, and resolved, in future cases, to adopt that plan unhesitatingly, which modern science has shown to be the most rational, and modern experience the most successful treatment. But, it may be asked, why resort to the old operation of opening the sac, when a less hazardous-in most cases equally eftectual, and when so, in all more successful-operation can be performed; viz., that devised by Mr. Gay? My reason simply was, that I had no knife which I thought properly adapted for it. The difficulty-what there is -of the operation appears to me to consist in introducing the point of the knife betwixt the sac and Gimbernat's ligament; and if its beak is not properly fitted for its work, of course the difficulty to the operator and danger to the patient will be increased. I, however, before opening the sac, satisfied myself of the comparative ease with which Mr. Gay's oper'ation may be accomplished; and, when cases present themselves, shall certainly avail myself of it. Its simplicity, and comparative freedom from dangerous results, will induce many to resort to it earlier, and with less compune-tion, than to the old operation, respecting the fatality of 'which one has read and heard so much. Not that I share in the fears entertained by some of the operation for hernia, on account of the large mortality that attends it; for, from m3y own, certainly very limited, experience, I by no means consider it the fatal operation that some do, believing that the fatality arises, not from the operation per se, but from its not being performed when a fair chance of recovery exists; viz., before the supervention of inflammation and its consequences. I verily believe, if the stricture were immediately liberated by the knife, when a fair trial of the taxis by one accustomed to its application has failed, and no repeated trials by different individuals were allowed, we should find the operation to be much more successful, and the gloom that seems to hang over some minds in corinexion with it would be greatly and speedily sdispelled.

THzES instructive Lectures on cerebraldiseases weredelivered by Dr. TODD on various occasions during the last ten years, and are now published in a collected form "at the expressed desire of a large number of those, to whom they were addressed". Their sterling merit amply justifies the author in responding to the call thus made.
The subjects treated of are, various forms of Paralysis (in Lectures I to xvi inclusive); Syphilitic Disease of the Dura Mater (in Lecture xviI); Trissnus and Tetanus (in Lecture xvii)~hews (IaLeet'=xx); and L Bphm leture xx). ae tie lectures ha, beu give. from tim totha. on c caes as requiird th.. no subjec is ofA treated of in varous potts of te work, w po instead of analysing each lectus separtly, to mko , few selections from the author's remarks, as they can be collctad from the various passages in which they occur.
PARALYSIS FRox DIsEAsE OP THE BRAIN. In the vaius lectures which treat of this subject, we meet with many instructive remarks. In one of the cas (Thomas HE wi aged 40, lectures ix and ILI), there was fixed pain in the left side of the head; paralysis on the opposite aide to that of the pain-the paralysis having been preceded by convulsive movements, and being incomplete and accompanied by rigidity of the muscles; and irregular movements of the eyeballs and double vision. These circumstances led Dr. Todd to make the following diagnosis: " The lesion is of an inflammatory kind, and is principally and primarily meningeal. So far I can speak without hesitation; buit in determining the precise locality more difficulty is experienced. I have no doubt, lhowever, that it is so situated as to affect the optic and third pair of nerves; and, from the seat of the pain, which the man has always referred to the left parietal bonie, and should assign as its locality the dura mater, and the other membranes in the vicinity of the anterior and inferior angle of that bone; thence the disease has extended perhaps along the fissure of Sylvius, and thuis it has come to involve the optic and third pair of nerves. It must be obvious, however, tlhat the disease miight readily have set up first in the pia mater, and may have involved the origin of the nerves through some other partts of the brain, producing precisely the same train of symptoms." (pp. 35-6.) The post morem examination of the case showed the durs mater to be healthy; and further showed an error in the diagnosis, in not having indicated the optic thalamus as the part of the brain secondarily affected. The idea of the seat of the disease was also erroneous. The diagnosis was, however, correct so far as it stated the disease to be on the left side of the brain, to be seated in the meninges, and to be inflammatory.
On certain points in connexion with this case, Dr. Todd makes some remarks which cannot fail to increase confidence in him as a careful observer and an honest teacher. VALUE oi Ranott iN DIAGNOSIS. "It is a duty we owe ourselves to scrutiniise particularly any errors we commit, either in diagnosis or in practice. Depend upon it, if you do this faithfully, you will derive great benefit from it; your experience will be intinitely more profitable than if you slur ov'er your mistakes witlhout explanation or inquiiry. Oni this account, I make it a rule never to pass by any mistake made here in diagnosis or practice; and I feel that, in commenting upon such to you, I am far more likely to benefit both you and myself, than were I to dilate at length upon successful cases. The successful cases speak for themselves; the failures we wotuld fain throw a veil over; but be assured, in so doing, we benefit neither science nor ourselves.
"A diagnosis may be erroneougs in two ways; the one, in which it is absolutely incorrect; the other, where the principles upon whichl the diagnosis is conducted are sound, and have not bee violated, but still the details of the diagnosis may not be absolultely correct. 'rhe first of these is likely to happen when an examinatioui of tlhe patienit's condition has not been sifficiently careful; or where the information supplied to us has been inconmplete or inaecurate; but the second may occur from the absence of symptoms of a sufficiently distinctive character to give us the precise information we require, or where the attention has been unduly occupied by the inordinate development of some particular symptom." (pp. 40-7.) The error in the case referred to was caused partly by the difficulty of determining the precise locality of lesions in brain disease, and partly by the prominence and very local character of the pain. A CONDITION OF THE MUMCLES Irl PARALYSED INxES. In connexion with the ca6e above referred to, Dr. Todd made some remarks on this subject, which will be found at pges 32-34 of his work: and he aqain comments. on it in a subsquent Lecture (ix) from which we must make a quota ;. ; h1 a.M times had occson to dlrc6t your attetion to o-e _srn~siss of the musces of the paralysed limbs in eas of gshtul heiplads. This point has not hithato received the it deerves, sad many otherwise interesting narratives of css ae conpatively of little value, from the omission of SU mention of this symptom. Now I hope, as we go on, to show jo that from the state of the muscles of the palsied limbs, espeially of the upper extremity, as being nearest to the seat of ae lesion, you may draw inferences as to the nature of the lesion which will afford important aid for diagnosis and prognosis; and I propose to make this the basis for an arrangement of cases of h^emiplegi, which I trust you may find useful in practice. "Lking, then, to the state of the muscles of the palsied limbs, I arrange cases of cerebral hemiplegia in three classes: "The firSt class consists of those cases in whicb the muscles of the paralytic limbs are completely relaxed. The limlbs are loose and flaccid, and if you flex the forearm upon the arm, or the leg upon the thigh, you find no resistance or opposition to that movement. Wlhen you feel the muscles you find them lax and flabby, contrasting more or less with the firmness and plumpness of those of the sound limbs, and tbey are more or less wasted according to the period of time which has elapsed sinee the paralytic seizure.
"In the second class, I place thiose cases in which the paralysed muscles exhibit a certain amount of rigidity, which rigidity Am existedfrom the tnoment of or soon after the attack. This rigidity varies in degree from an increased plumpness of the biceps of the arm and the hamstring mnuscles in the thigh, and a resistance on the part of these muscles to extension of the forearm or leg, up to a contraction almost tetanic. The nutritition of the muscles in cases of this class is not materially weakeed at first, and the wasting is conseqtuently either nil, or to as very trifling extent. lf, however, the palsy persist. the miiuscles waste, although not so fast as in the first class of cases. "In the third class, we find cases with rigid rnuscles likewise.
In these cases the rigidity is a late phenomenon. It does not occur for some time after the paralytic seizure. The cases of the first class often pass into tlhis. The wasted and relaxed muscles after some time graduially acquire more or less of ten. skon; they become shortened, and appear like tight cords stretched between their origin and insertion. The tension is most manifest in the flexor muscles, and the limbs assume the state of more or less flexion, especially the tipper extremity. The forearm becomes strongly contracted on the arm, and thie fingers flexed into the palm of the hand, which is liable to be initated by the growth of the nails." (pp. 173-75.) The indications of treatment afforded by these conditions are thus concisely pointed out: "When the condition of rigidity is present early, youir patient will bear local bleeding or local counter-irritation, or bothi; and may derive benefit from these measures, provided other symptoms do not contra-indicate them. The state of complete relaxation affords no indication for antiphlogistic treatument, but, on the contrary, in many of the cases in which it occurs it should be regarded-as affordin a contrary indicationi. As to that condition in which the muscles assume the contracted state gradually, and some time after the paralytic seizuire, I wish mucl it were in my power to suggest some means of arresting it. Some slight benefit is gaiined by subjecting the limb to frequent estension at stated periods in the day; this I believe will retard the contraction, so long as diligently persisted in, buit when it has been laid aside, the contraction will go on ju!Qt as if the extension had never been practised." (p. 34.) These conditions of the muscles in paralysis are each illustrated by cases, which form the subjects of Lectures x, xi, pnd xii, and which, with the theoretical and practical comments on them, are worthy of most careful perusal.
The condition of the muscles in brain disease attended with irritation consists, as we gather from various parts of Dr. Todd's book, either in their readiness to contract on the spplication of a stimulus from without, to be thrown into convulsions without apparent cause, or to assume a permanently rigid state. The lesions capable of producing this condition are the presence of a hsemorrhagic clot, not surrounded, or only partially so, by white softening, and tearng up * greater or less extent of sound brain; fracture with depresion of the skull; haemorrhage within the nium, as from iury of the middle meningeal artery or is beaneM; or effusiou of fluid in the subarachnoid or _id spww. On1 the other hand, that form of rigidity which comes on gradually in pwalytic cases is believed 1?y Dr. Todd to be conected with a cicatrising process in te brain; but he admits that further observations are nex sary to prove this point. The permanently rigid state of the muscles is, howcver, though at first arlsing from "'a irritated or excited condition of the nerves", maintained by the assumption of a similar condition to that into which those about ankylosed joints are apt to fall.
Dr. Todd has studied with great attention the effects of galvanism on the functions of the nervous and muscular systems. Numerous allusions to the subject occur in the work; but we can extract only from Lecture v the following remarks on "You remember that on several occasions we passed a galvanic CUITent through the paralytic and the souud limbs in this cas" (paralysis from softening of the left corpus striatum). " This was done, as I explained to You at the time, for the purpose of ascertaining whether any irritant disease existed within the cranium, at the seat of the paralysing lesion. If, on-passing the galvanic current, youi produce less contraction in the paralysed than in the sound side, then you may judge the cause to be of a depressing kind; if, on the other hand, the cointractions in the diseased limb are the strongest, then you mav conclude that the condition of the centre which causes the paralysis is irritative. But then you muist bear in mind that irritation is not always inflammatory." (pp. 101, 102.) Tun RELATION OF RENAL DISEASE To APOPLEXY A"' PARALYSIS iS instructively commented on in several lectures. A case is related (Lecture vi) of a man who, having for some time suffered from gouty symptoms, died in King's College Hospital, after a succession of attacks of an epileptic nature, conjoined with paralysis. first on the right side, and lastly on the left. Apoplectic effusions, both recent and of long standing, were found in the brain; and the kidneys were " very contracted, the cortical substance much wasted, fissured, and granulated oil its surface, the tubular substance healthy, an(d the capsule thickened." Dr. Todd calls this the gouty kidney; but says that it occurs in cases.
where there is no evidence of gout. The coats of the arteries contained numerous atheromatous deposits. The heart was much dilated and hypertrophied, and the fibrous basis of its valve was much thickened.
The sequence of events in such cases as this is thus described by Dr. Todd: " First, the mau gets into a general gouity condition; and the elinmination of the mnorlbid material gives rise to an irritation of the kidney, wvhicli at longth Pa-nsumnes the form of goity kidney, or, if you will, chronic nephritis; and this clhronie nephritis incapacitating the ki.lney for the perfect discharge of its functions is the cause of all the subsequient mnaladies; the blood becomes contaminated, deposits take place in thle tissuie of the heart's valves, in the large arteries, aind in those of the brain; the diseased arteries of the brain beeome insufficient channels of' supply; white softeriing is the consequence, and many of thef unsupported anad wlhealthy capillaries at length give way." kpp. 11-1-15.) Dr. Todd objects to the common notion that the hypertrophy of the heart in such cases gives rise to the apoplexy; for, he says, "The actual force witllh which the i-loo(d circuilates in the morbid arteries is proliably less than in hiealtlh. The apoplexy is, in fact, duie to the liseas(ed state ot the arteries, which renders these walls an inadequate support to their eontents, and to the diseased state of brain", (white softening, dependent on imperfect nutrition) "which imperfectly supports the arteries." (p. 116.) In another case (Lecture viii), the man had been of intemperate habits, but had been a teetotaller for eight years. Six or eight months beforc admission into hospitl, he began to be troubled with frequent micturition. On admaission, the quantity of urine was large, sometimes amounting to nine or ten pints in a day, of low specifc gray ty, and albuminous. The scanty precipitate which it threw down consisted of epithelium, transparent casts of uriniferous tubes, and a few cells containing a large quantity of fat. There was dropsy, amounting only to moderate BIBLIOGRAPHICAL NOTICE.
MiT 12, of the legs, and sight p of the fc. Aft inin in thehospital four months, he died suddely in an attack of coma, unattended by oonlsions. On peat mortem examination, there was found to be an apoplectic Clot in the fourth ventricle. The kidneys we runk, granulated, and fissured; and the tubes were stripped of opithelium.
In cases of this kind, although a large amount of urine was passed, it principally consisted of water, the excretion of wrhich is favoured by the thinness of the walls of the uriniferous tubes, while the absence of epithelium impedes the excretion of organic matter. Hence arise, Dr. Todd observes, poisoning of the blood, imperfect sanguification, and disordered nutrition.
In Lecture xvi the subject is again returned to, in commenting on the case of a patient who had suffered from epileptic coma and convulsions, lead-palsy, colic, and gout; and who at last died, after a rapid succession of epileptic fits. The kidneys were found extensively diseased: the urine had been albuminous during life. BLEEDInG IN APOPLExY. In his sixth Lecture, Dr. Todd takes occasion to express his condemnation of bleeding in cases of apoplexy, as a routine practice. He refers to Dr.
CQpeman's Collction of Cases of Apoplexi, from which the following results are gathered: I "' Of 155 cases in which the treatment was specified, 129 were bled, and only 26 were not. Of the 129 who were bled, 51 recovered, and 78 died-the recoveries being about I in 2i, the deaths in 1 in 11. Of the 26 who were not bled, 18 surived, and 8 died; the proportion of recoveries being 1 in 14, and of deaths 1 in 3j. Eighty-five of the cases were bled generally and copiously; and of these, only 28 recovered, and 57 died; in other words, two in every three cases terminated fatally." (pp. 117-18.) The conditions under which Dr. Todd sanctions bleeding in apoplexy are "a full plethoric habit, with too much blood in the body, and a sufiiciently strong heart". He observes, very correctly, that bleeding, when it does good, does so by relieving the cerebral congestion. But in many -perhaps most-cases, there is no cerebral congestion; and the hsemorrhage is of a kind not likely to be stopped by establishing another hemorrhage elsewhere. The treatment which he advocates in most cases of apoplexy consists in " purging, shaving the head and keeping, it cool, and perhaps blistering".
HYSTERICAL PARALYstS forms the subject of some observations in Lectures I and xiii. It occurs sometimes in the form termed hysterical aphonia; sometimes as hysterical paraplegia, affecting one limb only, or both lower extromities; and sometimes, though rarely, it affects both the limbs on one side. The diagnosis of the latter form is thus given:-"In the hysterical hemiplegia, neither the face nor the tongue is affected; the palsy is limited to the uipper and lower extremity, and is often not complete; the muscles are generally relaxed, but do not suffer much in their nutrition, as compared with those of the other side; now and then, one or both limbs may be affected with a spasm of some of the muscles, or may have a tendenjcy to piss into cataleptic rigidity. In walking, when the pawlsy is pretty complete, the leg is drawn along, as if lifeless, sweeping the grounid." (pp. 203-4.) Further points on which the diagnosis of hysterical paralysis, whether hemiplegic or paraplegic, depends, are:-" 1. The hysterical constitution of the patient herself or of her family: and there are certain signs which, as you know, are held to be indicative of the hy8steical diathesis, such as a lax condition of the tissues generally, a peculiar fulness of the upper lip, drooping of the upper eyelids, etc.
"2. The absence of signs of lesion of the nervous centres. "3. The characters of the paralysis itself; the absence of palsy of the face and tongue; the peculiar movement of the leg m progression; the fact of the paralysis not being complete, the muscles not beiDg so much wasted, and the fact of the patient being sometimes able, under the intluence of strong emoWton, to use the paralysed limb as well as the sound one, or nearly so. But you will not fail to recollect that, even in de. cided lesion, the paralysed arm is sometimes moved in yawning Or sighing, or under strong emotion." (p. 277.) Epuu"ro Huinip uu is d r ae . this ten, Dr. Todd design that form of h l which follows and is caused by the epileptic paroyMs.
Theparalys nthese cass i trasiet, pasng off in a few hours, or oven minutes. He ob'ects to any explantion of the paalysis being founded oZthe presence of a temporary congestion of the vessels of the affected part of the ence. phalon. The parlysis occurs generall on that side wich has been most convulsed; and hence Dr. Todd ascibes it to an undue exaltation of what he terms the "polar force" of the brain, inducing, "subsequently, a state of depression or exhaustion, not only in the parts primarily affected, but in parts of the brain connected with them, according to the degree of the primitive disturbance; just as undue muscular action exhausts the muscular force." TREATMENT oFr HEMIPLEGIA. We extract the following concise directions on this head from Lecture xv.-" Looking over all the forms of hemiplegic paralysis" (viz., from diseased brain, diseased spinal cord, epilepsy, chorea, and hysteria) "which I have described, the antiphlogistic plan of treatment is strictly and fairly applicable only to that, in which the rigidity of the paralysed muscles occurs early, and it must then be employed proportionately to the strength and age of the patient; but recourse to large bleedings is certainly not justiflable in aiy case with which I am acquainted. By a large bleeding, I mean such as exceeds ten or twelve ounces taken at once. The remedies to be used in such a case are mercury, free purging, and general or topical bleeding; bat in the other forms of hemiplegia, no extensive antiphlogistic treatment should be adopted, and especially in the simple hemiplegia without loss of consciousness, which is purely an atrophic disease. You should adjust the diet to the powers of the stomach; keep the patient in the horizontal position, as quiet as possible; and carefully guard against all causes of mental agitation or excitement. " Many advocate very much the use of mercury in hemiplegic cases. It is a valuable purgative, perhaps the most valuable we possess, and as such it may be used in nearly all the forms. But for its specific influence, it ought only to be employed where cerebral inflammation exists, either primarily or around a clot, or where there has been a syphilitic taint. To use it with this object in the atrophic bemiplegia, or in apoplexy, appears to me to be worse than useless. Its employment in this way is also to be especially avoided, when there is renal disease and albuminous urine.
" Then, with respect to the treatment of the paralysed limbs, some have stron<gly recommended the use of strychnia, while others have as strongly advocated the employment of electricity; but when the paralysis is the result of cerebral lesion, neithier of these remedies promises much good, and they very frequently do harm. In the administration of strychnia, the greatest caution must be used; and if electricity be employed, it should be of feeble intensity." (pp. 318-20.) IODIDE OF POTASSIUM is thus commented on by Dr.
Todd, in a lecture (xvii) on syphilitic disease of the dur mater:-" The extraordinary influence of iodide of potassium in controlling syphilitic periostitis, is highly deserving of your attention. We hear a great deal about specifics, and many medicines have the name with very slender claims to it; but if there is anything, in addition to quinine, which deserves the name of a specific, it is the iodide of potassium, for syphilitic periostitis.
If you have a pure case, it acts like a charm, so that the treatment materially aids the diagnosis; for we may fairly set it down, that if the symptoms yield completely and at once to the influence of iodide of potassium, there is a strong reason to suspect that the disease is probably syphilitic. "B But, altbough iodide of potassium unquestionably exerts a wonderful influence over these syphilitic periosteal alffections, nothing is more cert-ain than that its effect is far from being permanent. It is very common to meet with cases of periostitis which at first yield readily to the influence of iodide of potassium, and the patient continues well for a time, when all the old symptoms return.
"The knowledge of these clinical facts teaches us that we must not speedily abandon the use of the iodide, or of iodine in some other form, in cases of this description. In the resent state of our knowledge, we can scarcely determine whether the iodine acts by eliminating the syphilitic poison, or as an anti. dote. Possibly, it may act in both ways; it may at once pro BIBLIOGRAPHICAL NOTICES.

419
Xai the fi ifi, and so inrame the amount of ,a,tS's Oasted from the blood; and it may unite with the yphitic oison, and form an innocuous compound, of whicb, awer, i. iodine element disappears more quickly than the hlawing, after a time, the syphilitic in undisputled way the system. " Inl such cases, we must trust to the repeated use of iodine as one element of cure, care being taken to watch the constitu. tion of the patient during its administration. And we may aid the inifuence of the iodine, by the occasional use of mercury, either at the same time with the mercury, or, as I prefter it, alternately,-that is, giving first a shlort course of mercury, then of iodine, then of mercury, and theu omitting both, and uing only tonic means, both medicinal and hygienic, resuming, if occasion should demand, the mercurial and iodine treatment. And you will also find great benefit from the prolonged use of well-made decoction of sarsaparilla, or of cod's liver oil, or of both. " But you must never lose sight of the fact, that time is an important element of cure in these cases; and, therefore, we must be careful not to weaken the powers of our patients by our treatment; lest, by so doiDg, we should not only retard their favourable progress, but give a stronger hold to the poison. " It will be our duty, then, to encourage our patients to ex. pect a favourable issue; impress upon them the necessity of a steady perseverance in a general plan of treatment, anid to point out the dangers of swerving from the hygienic or dietetic rules laid down for them." (pp. 383-86.) Dr. Todd, however, admits that iodide of potassium is useful not only in syphilitic periostitis, but also in periosteal rheumatism and gout. At p. 391, he relates a case which had been furnished to him by Dr. Kennion, of Harrogate. in which an officer, having received a blow from a pistol on the forehead, was seized with pain in the right temporal bone, loss of flesh and strength, and epilepsy. After some time, a swelling was perceived in the right temporal region. Mercury and various other remedies having been given without any effect, iodide of potassium was given three times daily in doses of five grains, gradually mereased to fifteen. In two months, the pain had entirely subsided; and the fits disappeared. In this case, there was no syphilitic taint.
The extracts that we have made-and which are only a part of those we had noted down -will sufficiently show the high scientific and practical value of Dr. Todd's Clinical Lectures. The perusal of the work has afforded ,us, as it must do to all who read it, both pleasure and instruction; and of still greater benefit must the lectures, as orally delivered, have been to those students who had the advantages of seeing in the hospital the patients who formed the subjects of them, and of being able at once to refer to an able teacher for explanation of such difficulties as might arise in their minds.
In his preface, Dr. Todd promises:-" Should I have not over-estimated the fitness of these lectures for publication (and I am not without givings on this point), I shall venture to furnish some further contributions of a similar nature, not only on nervous, but on other diseases likewise." Dr. Todd's "misgivings" are quite unnecessary; and we trust he is sufficiently aware of this fact, to be already preparing the promised "further contributions" for publication. In the mean time, every practitioner of medicine should make himself master of the presenit series of lectures, which will render him more capable to understand and treat a formidable class of di"ses of every day occurrence. PRACTICAL OB8ERVATIONS OX GOUT AND ITS COXPLICA-TIONS., and on the Treatment of Joints stiffened by Gouty Deposits. By T. SPENCER WELs, F.R.C.S., etc. pp. 288. London: 1854. THIs practical workeonsists of nine chaptersand anappendix.
The first chapter treats of Gout and its Causes; the second, of Gout as modified by Rheumatism; the third, of Gout as modified by 8yphilis; the fourth, of the Morbid viz., the manner in which the syphilitic poison may, by the alterations which it produces in the blood, modify the cha. racter of other diseases. Avoiding the consideration of pri. mary syphilitic affections to which a gouty person may expose himself, he proceeds to point out, " first, how various forms of secondary syphilis may show themselves in gouty patients, and be mistaken for the effects of gout; secondly, to describe a condition of the whole system which sometimes materially modifies the symptoms of gout and the effects of remedies, this condition being an effect of latent syphilis." Under the first head, Mr. Wells notices syphilitic purpura complicating chronic goit; syphilitic cutaneous eruptions in gouty subjects; syphilitic synovitis and periostitis complicating chronic gout; syphilitic onychia, with gouty deposits on the fingers; s.yphilitic ophthalmia in gouty patients; general debility, tw3dium vitin, and rapid decay, occurring about middle age in gouty persons, as a consequence of syphilis; and the phst/siis ayphdlitica of Sauvage and Cullen.
In the treatment of these diseases, iodide of potassium is the main remedy; and it is, Mir. Wells observes, most fortunate that, while it is a valuable remedy in chronic gout, it has also a specific power over many forms of secondary syphilis.
In his fourth chapter, the author of the work before us recognises fully the fact that gout, being a blood-disease, may produce its effects on any organ whatever of the body, and in either sex. This statement, however, he by no means puts forward as new.
"It would further appear that a certain degree of bodily vigour is required for the formation of the lithates in excess, and for their deposit about the joints with the corresponding symptoms of an acute attack of articular gout. Thus we see strong men afford the most frequent examples of the perfect type of gout. Delicate men are victims to the less marked but more dangerous varieties of the disease. Such females as are subject to the more regular attacks, are always of a stroii and somewhat mauline frame, 'but the sex as a general rule are only liable to irregular and internal attacks. In Southern Europe, the warm climate, the inactive, luxurious, somewhat effeminate mode of life, the peculiar education, together with comparatively abstemious habits, give to the male something of a feminine character or constitution, and his diseases assimilate in many respects to those of the females of our climate. Thus, regular attacks of articular gout are exceedingly rare in the South, but the internal varieties are so common, that Italian physicians especially are constanitly speaking of arthrith' arteritis, a.thitic apoplexy, arthritic neuralgias arthritic dyspepsia, arthritic nephritis, and so on. They belong rather to the old schools of observation and nosology, than to the modern patbologieal school, and remind one very strongly in their conversation and writings on gout, of the works of Stoll, Hoffmann, Van Swieten, Musgrave, etc., which abound with instances of mental alienation, epilepsy, melancholia and hypochondriasis, coma, obstinate cutaneous affections, ophthadmi.a, anginia pectoris, and various internal inflamnmations, alternating with attacks of external gout, relieved by the external affection, produced or restored by its retroces.
sion." (pp. 115-17.) Mr. Wells lays it down as a rule, that the more healthy and vigorous is the person, the further are the parts attacked by gout removed from the centres of life; and, as age advances, or as, from any other cause, there is an enfeebled circulation and bodily vigour, so the gouty matter comes at last to be not even thrown off in the joints, but to be carried to, and injure the function of the internal organs. He believes that when this is recognised, much Iwil be done towards establishing the law that j~BIBI_ ri AD i autrition br to depi of the lithats in the ibrous Ues about the joints, sa, in licate or enfeebled pers the same d geme lead to deposits of the phosphates in the fibrous is of internal organs." (p. 120.) The author then proceeds to sp of gouty affections of the brain, of fhe spinal cord, of the organs of the senses, of the heart and blood-vessels, of the lungs, of the subcutaneous fascii of the superficial muscles of the various cavities, of the fibrous coat of the testicle, and of the urinary organs. The remarks on these points are, though brief, deserving of attentive consideration.
It is common, in this country at least, to deny that females are liable to gout, or, at least, to say that this disease Is in them of very rare occurrence. Mr. Wells, however, not believing that a deposit, pain, etc., in the hands or toes, is an absolute necessity before the existence of gout can be established, points out various forms under which the disease presents itself. These formns are gouty dyspepsia, gouty hysteria, gouty ncuralgia; in short, " all the varieties of neuralgite and simulated inflammation, commonly called hysteric, frequently arise from the presence in the blood of the impurities which are the true characteristics of gout." We must make one extract from this part of Mr. Wells's book.
" Gouty affections of the itteras appear under vaious forms. When the attack is acute, pains in the back are complained of as hot andl drawitng, not extending down the thighs, but rounid the -hypogastric region. They are much increased at the menstruating period. The discharge is generally profuse, Rnd leucor. rhea continues more or less during the intervals, slightly tinged with blood. If cold local applications be used to suppress the dicharge, the pain is greatly increased, and general feverishness supervenes. If this state continue it leads to hypertrophy of the uterus in the unmarried, to repeated abortion in the married.
In the latter case, gouty concretions have been found on the surfaoe of the placenta. These are much more froquently the cause of abortion in the early muontlhs of pregnancy than is generaUy believed, and I have no douibt that gouty metritis is the origin of very many organic affoetions of the uterus.
"I have known some caes, and heard of many others, where the females of a family, the male members of whichl suffered from ordinary attacks of gout, have been subject to a kind of uterine catarrh, the leucorrlimal discharge being either thick d very irritating, or abundant and watery. Occasionally it eonsists of a milky gelatinoui fluid, wlhich, on dr,ying, is converted into a sort of chalky paste, consisting principally of the phosphate of lime, with soimie carbonate of lime and atnmoniomagnesia phosphate. This forn is very common in Southern Euope, especially among, English ladies who reside there. At times, the quanLity of earthy matter thus thrown off is quite .extraordinary. I lave been told of one lady, who said shte had passed enough to make her tombstone." (pp. 165-.6.) Passing over several parts of the book, we come to Chapter vir, which has the title of "The Cold Water Cure". -his heading might excite a feeling of suspicion in the nind5 of some that the author is not perfectly orthodox iu .hli opinions. We must remind such, however, that it by meaus follows that a useful remedy is to be condemned And despised because it has been pressed into the service of ignorant and unprincipled charlatans, and used as a panacea for all diseases to which flesh is heir. In hydropathy, kinesipathy, and many other pathies-always -excepting homecopathy-if they are analysed, we shall often find something really useful buried under a ponderous mass of absurdity. Mr. Wells regards hydropathic treatment as inapplica ble " if any symptoms of acute gout, or of gouty febrile excitement, are present or threatened"; but if the patient is in a purely chronic condition, this treatment may be bene-5cial; the amount of benefit varying greatly, according to the form of the disease, and the amount of the general constitutional depression which it has produced-a point which must always be ascertained. In the practical application of tbe water cure, the author deprecates the excess to which it is sometimes carried; and correctly observes, that the Mr. el pc gre rance on the iodid&fpOef oua as a remedy in gout; and in this we beHiee he will be borne out by the expenrence of numerous practitioner. in this country, who have been for some yers in the habit of recommending and using this medicine. Except whev, gout is complicated with syphilis, when twenty-four graing daily may be required, he finds one graiin three times a dayas much as can be given for a length of time with benefitand often one grain daily, in divided doses, is quite suficient., We recommend Mr. Wells's work on Gout to the notice of our readers, as likely to afford material both for instruction and for reflection. The author bring to his aid both a fair amount of knowledge of the literatlure of the subject, and also of practical experience, as well as a will to shake off the absurd, but now gradually decaying notion, that the external presence, in some particular form, of^disease is necessary to establish the actual presence of that disease. This communication consisted of a synopsis of 115 dissections of patients dying in Bethlem Hospital, and was accompanied also, by a careful analysis of the morbid appearances observed both in the brain and the other organs of the body. A paper published in the Society's " Transactions" for the year 1845 contained the post-mortem records of 175 insane patients; and the 115 additional cases supplied by the present paper give 290 dissections of insane patients, an epitome of which gave the following results. In 226 patients who died insane, the pia mater was infiltrated. In 207, effusion had taken place into the ventricles. In 184, turgidity of the blood-vessels in the brain or membranes wa.s observed. In 117, the arachnoid coat had become thickenod and opaque. In 64, the colour of the brain appeared altered from its natural hue. In .51, bloody points were large and numerous upon the cut medullary surfaces; while, in 40 instances, blood.

REPORTS OF
was effused, even sometimes to a considerable amount, witlhin the cranium, and which evidently proved the immediate canse of death in most of these patients. According to the above data, the auithor desired to repeat the same general conclusions formerly enunciated when discussing the pathology of insanity, viz., tliat-Ist, infiltrations of thte pia mater; 2ndly, effusion of fluid into the ventricles; and, 3rdly, targidity of the cranial bloodvessels, were the principal as also the most usual diseased alterations of structure which pathologists might confidently anticipate in the great majority of cases of patients dying while labouring under symptoms of mental alienation.
Dr. SUTHERLAND considered that the great means which must be adopted in order to determaine the nature of mental diseasewas, the study of the minute anatomy of the brain. In certai cases of chronic insanity, the convoluitions were not so well defined, and the bands of Foville were not so clearly visible. But even this chang-e was absent in acute cases. Mr. HOLMES COOTE said, that no connexion could be traced betweeni the symptoms which occurre(d during life, and the appearances which were seen after deatlh. The microscope and chemical experiments were necessary in order to investigate the trute natuire of the disease. He believed the gangrene in the lungs, whlichl killed so many lunatics, was owing to disease about the origin of the pneunmogastric nerve.
Dr. GUGGENBUHL said, that malaria had great counexion witb cretinism, which occurred in low and marshy grounds in Switzerland, but was absent in higher grounds. In one village, ,( baueful was the influience of the malaria, that even animals became idiotic. This malaria seemed to be of a peculiar descriptioni, for in Holland, a flat and marshy country, the disease was uincommon; in Hungary, ow the other hand, it was frequient.
He considered that many different causes combined to produce cretinism.
Coot, Dr. Garrod, and the President, Dr. Webster replied at length to the observations of the vrious pekws.